Practice n
Post-Traumatic Stress Disorder
in a Nursing Context by Marissa L. Bowsfield and Joti Samra
Introduction
Post-traumatic stress disorder
(PTSD) is a mental health disorder
that is classified as a trauma-and
stressor-related disorder by the
American Psychiatric Association’s
Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition
(DSM-V). The twelve-month prev-
alence rate among adults is
estimated at 3.5%, and lifetime risk
is estimated at 8.7% (APA, 2013).
PTSD can occur at any age after
the first year of life, and symptoms
are typically evident within the
first three months after exposure
to the traumatic event. Howev-
er, it is possible for the onset of
PTSD symptoms to emerge sev-
eral months or even years after
the event; this is referred to as
“delayed expression” (APA, 2013).
Workplace Incidence and Impact
Occupational Health nurses may
encounter PTSD or PTSD-related
symptoms in employees as the
result of critical incidents or emer-
gencies in the workplace. The
International Labour Organization
identifies a range of situations that
may occur in the workplace that
have the potential to put employ-
ees at risk for PTSD, including
violence or threat of violence, sui-
cide, inter-employee violence and
crime, fatal or severe injury, and
sudden death or medical incident
(Braverman, 2011).
Although psychological symp-
toms related to PTSD are generally
closely associated with the traumat-
ic event, response factors relating
to environment and care after the
incident can work to exacerbate
or attenuate negative psychologi-
cal outcomes (Braverman, 2011).
26
Being aware of the causes and
symptoms of PTSD will enhance
the degree to which Occupational
Health nurses are able to contrib-
ute to the psychological health of
affected employees.
Diagnostic Criteria
Post-traumatic stress disorder
results from exposure to a trau-
matic event, with symptoms that
fall in four clusters:
• intrusion
• avoidance
• negative alterations in cogni-
tion and mood; and,
• alternations in arousal and reac-
tivity.
The American Psychiatric Associa-
tion (APA, 2013) criteria for PTSD
include the following:
Criterion A: Stressor
The person was exposed to:
death, threatened death, actual or
threatened serious injury, or actual
or threatened sexual violence, as
follows: (one required)
1. Direct exposure.
2. Witnessing, in person.
3. Indirectly, by learning that a
close relative or close friend
was exposed to trauma. If the
event involved actual or threat-
ened death, it must have been
violent or accidental.
4. Repeated or extreme indirect
exposure to aversive details of
the event(s), usually in the course
of professional duties (e.g., first
responders, collecting body
parts; professionals repeated-
ly exposed to details of child
abuse). This does not include
indirect non-professional expo-
sure through electronic media,
television, movies, or pictures.
OOHNA JOURNAL n Fall/winter 2015
Criterion B: Intrusion Symptoms
The traumatic event is persistently
re-experienced in the following
way(s): (one required)
1. Recurrent, involuntary, and
intrusive memories. Traumatic
nightmares.
2. Dissociative reactions (e.g.,
flashbacks) which may occur
on a continuum from brief epi-
sodes to complete loss of con-
sciousness.
3. Intense or prolonged distress
after exposure to traumatic
reminders.
4. Marked physiologic reactivity
after exposure to trauma-relat-
ed stimuli.
Criterion C: Avoidance
Persistent effortful avoidance of
distressing trauma-related stimuli
after the event: (one required)
1. Trauma-related thoughts or
feelings.
2. Trauma-related external remind-
ers (e.g., people, places, con-
versations, activities, objects, or
situations).
Criterion D: Negative Alterations
in Cognition and Mood
Negative alterations in cognition
and mood that began or wors-
ened after the traumatic event:
(two required)
1. Inability to recall key features of
the traumatic event (usually dis-
sociative amnesia; not due to
head injury, alcohol, or drugs).
2. Persistent (and often distorted)
negative beliefs and expecta-
tions about oneself or the world
(e.g., “I am bad,” “The world is
completely dangerous”).
3. Persistent distorted blame of
self or others for causing the

traumatic event or for resulting
consequences.
4. Persistent negative trauma-
related emotions (e.g., fear,
horror, anger, guilt, or shame).
5. Markedly diminished interest in
(pre-traumatic) significant activ-
ities.
6. Feeling alienated from others
(e.g., detachment or estrange-
ment).
7. Constricted affect: persistent
inability to experience positive
emotions.
Criterion E: Alterations in
Arousal and Reactivity
Trauma-related alterations in
arousal and reactivity that began
or worsened after the traumatic
event: (two required)
1. Irritable or aggressive behaviour
2. Self-destructive or reckless
behaviour
3. Hypervigilance
4. Exaggerated startle response
5. Problems in concentration
6. Sleep disturbance
Criteria F, G, and H require that
the symptoms persist for greater
than one month; they result in
significant symptom-related dis-
tress or functional impairment in
important areas of function (e.g.,
social functioning, occupational
functioning); and, the symptoms
are not the result of medications,
substance use or other illness.
Symptoms may also include
dissociative symptoms in reaction
to trauma-related stimuli. Deper-
sonalization is the experience of
being an outside observer of or
detached from oneself (e.g., feel-
ing as if “this is not happening to
me”, or, as if one were in a dream)
and derealisation is the experi-
ence of unreality, distance, or dis-
tortion (e.g., “things are not real”).
Effective Treatments
Effective, evidence-based treat-
ments exist for PTSD. For most
individuals suffering from PTSD,
OOHNA JOURNAL n Fall/winter 2015
Post-Traumatic Stress Disorder in a Nursing Context n Practice
the most effective treatment
approach involves a combination
of psychological treatment and psy-
chopharmacological intervention.
The International Society for
Traumatic Stress Studies (ISST) pro-
vides Treatment Guidelines that are
available at: http://www.istss.org/
treating-trauma/effective-treat-
ments-for-ptsd,-2nd-edition.aspx.
The individual Treatment Guide-
lines address 18 specific areas,
and were developed in 2005
under the auspices of the Post-
traumatic Stress Disorder (PTSD)
Treatment Guidelines Task Force
established by the Board of Direc-
tors of the International Society for
Traumatic Stress Studies (ISTSS).
[Editor’s note: In 2015, the ISST
initiated the process of updating
the ISTSS Treatment Guidelines
and Complex Trauma Treatment
Guidelines.]
The following is a summary of
the level of evidence for those 18
areas applicable to adults (Foa,
Keane, Friedman & Cohen, 2009)
[note: for the purpose of this arti-
cle, the areas applicable to chil-
dren and teens are not included.]:
Guideline 1: Psychological Debrief-
ing (PD) for Adults
• PD (or critical incident stress
debriefing) is typically a single-
session, semi-structured group
intervention method that takes
place following a traumatic
event; it is designed to reduce
and prevent negative and
unwanted psychological conse-
quences of involvement in or
exposure to a traumatic event by
encouraging emotional process-
ing through the normalization
of reactions and preparation for
future experiences.
• PD should take place shortly
after the traumatic event and
be based on an accurate and
current evaluation of the need
of those affected; interventions
should consider culture, devel-
opmental level, and local norms
around problems and coping
methods.
• Although PD has good face
validity, it is not considered a
psychological treatment nor
should it be used as a substitute
for psychological treatment;
randomized control trials have
not found PD to be effective in
significantly reducing trauma-
related distress or preventing
long-term psychopathology. PD
was widely advocated for use
as a group and individual inter-
vention in the 1980s and 1990s.
Overall, the quality of studies
that examine the efficacy of
debriefing is poor.
“Studies included since the first
edition’s guidelines support and
strengthen the original conclusion
that there is no evidence to suggest
that single-session individual PD is
effective in the prevention of post-
traumatic stress disorder (PTSD)
symptoms shortly after a traumatic
event or in the prevention of longer-
term psychological sequelae (Level
A). There remains an absence of
evidence with regard to group PD.”
(p.539-540)
Guideline 3: Early Cognitive-Behav-
ioural Interventions for Adults
• Early cognitive-behavioural inter-
ventions utilize strategies includ-
ing psychoeducation, stress
management skills training, cog-
nitive therapy, and exposure
therapy to prevent the develop-
ment of PTSD in the time imme-
diately following (weeks, months)
involvement in or exposure to a
traumatic event.
• These early interventions
should continue for 5-12 weeks
following the event, with ses-
sions ranging from 60-90 min-
utes each.
• Evidence from several ran-
domized control trials study-
ing a variety of traumatic events
(e.g., motor vehicle accidents,
industrial accidents, nonsexu-
al assaults) among men and
27
Practice n Post-Traumatic Stress Disorder in a Nursing Context
women found early cognitive-
behavioural interventions to be
robust in reducing PTSD symp-
toms and preventing chronic
PTSD. However, among female
nonsexual assault victims, these
interventions hastened recov-
ery but did not provide lasting
advantages over an assess-
ment-only condition.
“CBT is recommended as an early
intervention for survivors of relative-
ly discrete accidents who endorse
significant, enduring posttraumat-
ic difficulties in the aftermath of
trauma. It is more difficult to draw
definitive recommendations from
studies that include both physical
and sexual assault survivors because
the efficacy data from these are
less compelling at this time. In the
early aftermath of trauma (days
and weeks), treatment with CBT
should only be provided to sexual
assault and nonsexual assault survi-
vors following a period of sustained
monitoring and support.” (p.547)
Guideline 4: Cognitive-Behavioural
Therapy for Adults
• Cognitive-behavioural thera-
pies (CBT) encompass a range
of different treatments, includ-
ing exposure therapy, sys-
tematic desensitization, stress
inoculation training (SIT), cog-
nitive therapy, and combination
treatments.
n Exposure therapy involves a
series of procedures aimed
at helping individuals con-
front negative or harmful
thoughts or stimuli that are
feared and/or avoided.
n Systematic desensitiza-
tion involves the pairing of
trauma-related memories
and thoughts with muscle
relaxation with the goal of
inhibiting fear.
n SIT is an anxiety manage-
ment treatment that includes
education, muscle relaxation,
breathing retraining, role
playing, modeling, guided
28
self-dialogue, and thought has received support as treatments
stopping. SIT may also utilize for PTSD.... neither Dialectical
exposure techniques. Behaviour Therapy nor Acceptance
n Cognitive therapy (CT) is and Commitment Therapy has
based on the premise that received support as an effective
it is an individual’s interpre- treatment for PTSD.“ (P.551-554)
tation of an event, not the
Guideline 6: Psycho-pharmacother-
event itself, that predicts
apy for Adults 
emotional reactions; CT
• A range of pharmacotherapy treat-
involves the identification
ments exists for PTSD that target
of erroneous or problemat-
different neurobiological mecha-
ic thoughts, the evaluation
nisms, including the adrenergic,
of evidence for and against
hypothalamic-pituitary-adreno-
these thoughts, and the con-
cortical (HPA), serotonergic, glu-
sideration of whether they
tamatergic, gamma-aminobutyric
are the product of biases or
acid (GABA)-ergic, and dopami-
errors in an effort to develop
nergic systems. Serotonergic
more useful and/or realistic
drugs that are used as antide-
thoughts.
pressants are commonly used
• CBT interventions are typically
with PTSD patients (e.g., selec-
short-term individual programs
tive serotonin reuptake inhibi-
lasting for 8-12 sessions, at 60-90
tors (SSRIs), monoamine oxidase
minutes each. CBT often involves
inhibitors (MAOIs), and tricyclic
the completion of homework
antidepressants (TCAs).
tasks between sessions.
• Pharmacotherapy treatments
• The evidence supporting the
for PTSD should last for at
effectiveness of CBT in treating
least 8-12 weeks; recent studies
and preventing PTSD is robust.
involving SSRIs indicate that the
Randomized control trials have
maximum benefit of drug treat-
found exposure therapy to be
ments may not be achieved
particularly effective across
until the 36th week.
numerous studies with a wide
• The strongest evidence for the
range of affected samples.
use of pharmacotherapy for
“There is strong support for the PTSD exists for different classes
efficacy of individual exposure of antidepressants.
therapy administered to a range
“The strength of the evidence is
of trauma populations (men and
best for the different classes of
women; survivors of military trauma,
antidepressant agents tested in
physical and sexual assault, child-
most of the randomized clinical
hood sexual abuse, motor vehicle
trials (RCTs) on pharmacotherapy.
accidents, political violence....there
There is also good evidence from
is consistent support for cognitive
augmentation trials with atypical
processing therapy... Support for
antipsychotic agents. Finally, there
the efficacy of SIT is mixed but
are encouraging results with the
generally supportive, particularly
antiadrenergic agent, prazosin,
among female sexual assault vic-
the antidepressant, mirtazapine,
tims.... CT was found to be effective
and older antidepressants, such as
in reducing posttrauma symptoms
MAOIs and TCAs.” (p.564)
and received support from two con-
trolled studies of civilian traumas.... Guideline 8: Eye Movement Desen-
systematic desensitization has sitization and Reprocessing 
not received strong support from • Eye movement desensitiza-
well-controlled studies.... neither tion and reprocessing (EMDR)
relaxation training nor biofeedback is an eight-stage treatment that
OOHNA JOURNAL n Fall/winter 2015

includes history gathering, treat-
ment planning, patient prepa-
ration, systematic assessment
of trauma-relevant target(s),
desensitization and reprocess-
ing, installation of alternative
positive cognitions, body scan
for persistent discomfort spots,
and closure to address coping
needs for future use.
• The length and course of EMDR
treatment depends on the num-
ber of traumatic events identi-
fied and the individual patient’s
response throughout the stages.
• Randomized control trials have
found EMDR to be comparable
to other frontline PTSD treat-
ments, including psycho-phar-
macotherapy.
“EMDR is rated as a Level A treat-
ment for its use with adults. Quality
clinical trials support its use for
patients with PTSD. More stud-
ies need to be completed with
EMDR adapted for use with chil-
dren and adolescents. It currently
has a Level B rating for treatment
with this population.” (p.576-576)
Guideline 9: Group Therapy
• Group therapy approaches vary
in terms of theoretical orienta-
tion, degree of trauma focus,
and group composition. Regard-
less, group therapies capitalize
on efficiency, inclusion, social
support and social contact, and
the availability of social learning
through modeling.
• Typical group therapy approach-
es to PTSD treatment last for
10-25 weekly sessions of about
1.5-2 hours each. Studied group
therapies tend to be comprised
of a single cohort of people.
• Few well designed random-
ized control trials have been
run assessing group therapy for
PTSD; however, the evidence
that does exist indicates that
group therapy shows positive
change from pre-to-post treat-
1. (Agency for Health Care Policy and Research, US)
OOHNA JOURNAL n Fall/winter 2015
Post-Traumatic Stress Disorder in a Nursing Context n Practice
ment, with effect sizes ranging
from small to large.
“The empirical support for group
therapy as a modality for treating
PTSD is largely based on pre-
to-post treatment change. There
are promising findings from a few
AHCPR Level A studies and sever-
al Level B studies for superiority of
specific groups relative to wait-list
controls. At present, there is not
sufficient evidence to warrant rec-
ommendation of a specific type
of group therapy, to recommend
group therapy in favour of individ-
ual therapy, or to predict for whom
group therapy might be more or
less effective.” (p.578)1
Guideline 11: Psychodynamic
Therapy for Adults  difficulties in these areas. Rath-
• Psychodynamic treatment
approaches have the goal of
re-engaging normal mecha-
nisms of adaptation and coping
by addressing the unconscious
and making it conscious. This
process typically involves col-
laborative (patient-therapist)
sorting and organizing of the
patient’s wishes, fantasies,
fears, and defenses that are
affected by the event.
• Psychodynamic therapy usu-
ally involves 1-2 sessions per
week of about 45-50 minutes in
length and can be short term (a
few months) to long term (sev-
eral years). Session frequency
and duration of therapy is large-
ly dependent on the needs and
tolerance of the patient.
• There exist few randomized
control trials that investigate
the validity of psychodynam-
ic therapies. The complex and
interactive nature of psychody-
namic therapies make it diffi-
cult to test effectiveness; it may
be the case that psychodynam-
ic methods can be effective in
very controlled settings but less
so in real-world settings.
“Case reports and tightly rea-
soned scholarly works comprise
the bulk of the psychodynamic
literature (Level D). These can
neither provide ultimate tests
for psychodynamic hypotheses
nor define the limits of psycho-
pathology, theory, or technique.”
(p.583-584)
Guideline 13: Psychosocial Reha-
bilitation
• Many individuals with trauma
histories demonstrate signif-
icant disruptions in multiple
areas of life functioning, such
as: family relationships; roman-
tic relationships; employment;
and friendships. Psychosocial
rehabilitation techniques target
er than focusing on the internal
life of the individual, psychoso-
cial rehabilitation operates at
the union of the individual and
the broader community. Psy-
chosocial rehabilitation may be
particularly relevant for individ-
uals who have been multiply
traumatized or whose PTSD is
chronic in nature.
• Psychosocial rehabilitation
recommendations vary con-
siderably as a function of the
individual and the traumat-
ic event they experienced or
were exposed to. For example,
employment/occupational pro-
grams may benefit an individu-
al who was assaulted on the job
and wishes to find a new place
of employment, but they would
likely not benefit an individual
who has turned to substance
use to cope with witnessing a
traumatic accident at work.
• Some controlled studies indi-
cate that educational inter-
ventions for PTSD improve
outcomes; however, no such
support has been found for
family treatments. Unfortu-
nately, the bulk of research on
29
Practice n Post-Traumatic Stress Disorder in a Nursing Context
psychosocial rehabilitation has
taken the form of case reports,
naturalistic studies, and clinical
observations.
“With rare exception, psycho-
social rehabilitation techniques
have been evaluated primarily
in persons with serious psychiat-
ric illnesses. Although it is fair to
assume that many participants in
existing studies have co-occurring
(and often undiagnosed) PTSD,
results from randomized trials
targeting persons with PTSD are
sorely lacking.” (p.589)
Guideline 14: Hypnosis  tress; the second addresses the
• Hypnosis is a procedure that is
typically carried out via induc-
tion; this entails instructions to
disregard outside concerns and
to focus on the experiences
and behaviors indicated by the
therapist, or those that arise
more spontaneously. Hypnosis
can stimulate a narrow focus of
attention, enhanced suggest-
ibility, and alterations in con-
sciousness.
• Hypnosis is often integrated
with other approaches for treat-
ing PTSD, including exposure
techniques, cognitive restruc-
turing, and coping skills training
in an effort to manage trauma-
related hyper-arousal.
• The number of randomized
control trials assessing hypno-
sis for PTSD is limited, however,
the results are promising.
“The literature contains two ran-
domized, controlled clinical trials
of hypnosis for various types of
posttraumatic symptomatology.
The older study showed that
hypnosis significantly decreased
intrusion and avoidance symp-
toms, and seemed to do it in
fewer sessions than the compari-
son treatments. The newer study
found that hypnosis plus cogni-
tive-behavioural therapy (CBT)
had a larger therapeutic effect
for reexperiencing than did CBT
30
alone at the end of treatment,
although at a 3-year follow-up
the effects of CBT and CBT plus
hypnosis were equivalent. Thus,
early treatment including hypno-
sis produced greater symptom
reduction.” (p.592-593)
Guideline 15: Couple and Family
Therapy for Adults  movement, drama, or poetry in
• There are two primary approach-
es to couple and family therapy
for PTSD: the first addresses
the effects of trauma on families
and the relationships of trauma-
tized individuals and focuses
on relieving overall family dis-
role of the partner and family
members in assisting the indi-
vidual who was involved in or
exposed to the traumatic event
in their recovery and focuses on
enhancing the efficacy of social
support.
• Although programs for couples
and family therapy vary in their
structure and application, many
are incorporated into larger
treatment programs that target
the psychological consequenc-
es of trauma. The number of
sessions differ from program
to program; however, they are
typically structured with early
sessions focusing on education
about the treatment program,
trauma, and PTSD in general,
and later sessions focusing on
specific skills, including com-
munication, problem solving,
coping, and mutual support.
• The existing body of research
on couple and family therapies
for PTSD is extremely small and
tends to focus on combat vet-
erans and their partners. As
such, it is premature to rec-
ommend these approaches for
PTSD patients.
“The literature on couple and
family therapies with trauma sur-
vivors is severely limited. The few
empirical studies have significant
limitations. Most utilized small
OOHNA JOURNAL n Fall/winter 2015
samples and did not include a
control or comparison group.”
(P.596-597)
Guideline 16: Creative Therapies
for Adults
• Creative arts therapies involve
the intentional use, by a trained
therapist, of art, music, dance/
the therapeutic process. These
therapies utilize techniques that
have elements in common with
imaginal exposure. Imaginal
exposure involves the represen-
tation of the traumatic expe-
rience in the creative art, in
whatever form it takes.
• Creative arts therapies vary
widely in their treatment for-
mat, length, structure, and
degree of integration with
other approaches.
• Creative arts therapies have not
been tested via randomized
control trials and therefore are
not empirically supported as a
treatment approach for PTSD.
However, clinical case studies
have noted progress in the pri-
mary symptoms of PTSD and
in global clinical improvement
among patients.
“Specific creative arts therapy
treatments for trauma have not
yet been empirically tested. Evi-
dence for the effectiveness of the
creative arts therapies is based on
numerous clinical case studies....
Despite relatively widespread use
and application over a substantial
time period, the efficacy of the
creative arts therapies has not yet
been established through empiri-
cal research.” (p.600-602)
Guideline 18: Treatment of PTSD
and Comorbid Disorders
• There are three primary
approaches for treating PTSD
and comorbid disorders: the
first is an integrated approach
where disorders are treated at
the same time by the same pro-
vider; the second is a sequen-

tial approach where disorders
are treated one after the other;
the third is a single diagnosis
approach where just one disor-
der is treated.
• The integrated approach to the
treatment of PTSD and comor-
bid disorders is the most highly
recommended.
• About 4/5 of individuals with
PTSD have a lifetime rate of a
co-occurring psychiatric disor-
der; surprisingly, however, treat-
ments to address comorbid
conditions have only become
the focus of development and
study in recent years. The only
model that has been estab-
lished as effective through
randomized control trials is
Seeking Safety (SS) for comor-
bid substance use disorder.
This model involves present-
focused coping skills for PTSD
and substance use disorder.
“Treatment models for PTSD comor-
bidity offer a wide range of features,
including the types of trauma for
which they are designed, the use
of group versus individual modal-
ity, and the variety of techniques
offered. Some models are designed
from the start for comorbidity,
whereas others are a combination of
existing approaches already found
effective for each separate disorder.
Some studies address models that,
designed for only one diagnosis,
also showed impact on comorbid
conditions.” (p.607)
Recommendations for
Implementation
Management of clinical PTSD
requires assessment and inter-
vention by a psychiatrist or
psychologist (Mohta, Sethi, Tyahi,
& Mohta, 2003). However, the
Occupational Health nurse’s abil-
ity to recognize and differentiate
PTSD symptoms, as well as to take
the necessary actions to mitigate
pathological responses to trauma
is key in the management of criti-
OOHNA JOURNAL n Fall/winter 2015
Post-Traumatic Stress Disorder in a Nursing Context n Practice
cal workplace incidents (Baxter,
2004). Occupational Health nurses
should be involved in debriefings
and/or interventions soon after a
critical workplace incident, with
the focus being on education and
prevention (Braverman, 2011).
As PTSD is closely linked to a spe-
cific event, the first step in successful
prevention is to allow victims and/or
witnesses to identify the connection
between the event and his or her
symptoms (Braverman, 2011). This
identification of the stress response
allows those affected to recognize
that their reactions, although fright-
ening and oftentimes confusing,
are normal (Braverman, 2011). Fol-
lowing “normalization”, affected
employees may need to go through
controlled processing of their reac-
tions, guided by a mental health
professional (Braverman, 2011).
Using knowledge of PTSD and its
symptoms, the Occupational Health
nurse should identify those affected
employees who may benefit from
employee assistance programs or a
referral to community mental health
resources. An employee that is
assessed and diagnosed with PTSD
by a mental health professional will
likely be treated with a combination
of psychotherapy and pharmaco-
therapy (Mohta et al., 2003).
Conclusion
Although PTSD is a preventable
condition, its triggers and course
are variable and complex. This is
evidenced in the variety of afore-
mentioned interventions available
to PTSD patients. The application
of these therapies is beyond the
scope of the responsibilities of
the Occupational Health nurse;
however an awareness of their
existence and evidence-based
efficacy will allow for a more
complete understanding of the
disorder.
Dr. Joti Samra pursues a full spectrum of
research, consulting and educational activi-
ties in the field of workplace health. She
is the lead developer of Guarding Minds
@ Work (GM@W): A Workplace Guide to
Psychological Safety and Health, an inno-
vative online resource used by employers
to address psychosocial threats in the
work environment and was a member
of the Technical Committee that devel-
oped Canada’s first National Standard
on Psychological Health & Safety in the
Workplace (CSA Z1003/BNQ9700).
Marissa Bowsfield is a graduate student
in Clinical Psychology at Simon Fraser
University (email: mlb9@sfu.ca).
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Friedman, M. J., Keane, T. M., Kudler,
H. S., & Ursano, R. J. (2010). A guide
to the guidelines for the treatment of
PTSD and related conditions. Journal
of Traumatic Stress, 23(5), 537-552.
Mohta, M., Sethi, A. K., Tyahi, A., & Mohta,
A. (2003). Psychological care in trauma
patients. Injury, 34(1), 17-25.
31
Practice n Post-Traumatic Stress Disorder in a Nursing Context

Appendix: ISTSS Levels of Evidence (Forbes et al., 2010)

Level A Evidence for treatment is based on randomized control trials (RCTs) for individuals with PTSD.

Evidence is based on well-designed clinical studies but without randomization or placebo

Level B
comparison groups for individuals with PTSD.

Evidence is based on service and naturalistic clinical studies, together with clinical obser-
Level C vations that are sufficiently compelling to justify use of the treatment or to follow the
recommendation.

Evidence is based on long-standing and widespread clinical practice that has not been
Level D
empirically tested in the context of PTSD.

Evidence is based on long-standing practice by circumscribed groups of clinicians that has not
Level E
been empirically tested in the context of PTSD.

Evidence is based on recently developed treatment that has not been clinically or empirically
Level F
tested in the context of PTSD.

32 OOHNA JOURNAL n Fall/winter 2015

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